Response #1

Please comment or respond to this case study and differential diagnosis.

 

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case 1: back pain

Subjective

Chief Complaint: Back pain

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History of present illness:  The patient is a 42-year-old male presenting with a pain in his lower back for the past month.  He states the pain radiates to his left leg. He first noticed this when he went on a horseback riding, he previously completed without difficulty. Since then, he was not able to bend over or lift his baby which eventually caused him to miss work for weeks. He stated laying down alleviates his pain. He also reports 9 lb of weight gain over the past month. His appetite is good, and recently changed his diet to Mediterranean diet to avoid weight gain due to lack of activity. Current Pain level 6/10.

Past Medical History:

1. Benign prostatic hyperplasia (BPH): diagnosed last year

2.Hyperlipidemia (HDL): Diagnosed at age 40

Past Surgical History: None

Medications: Tamsulosin 0.4 mg PO daily

Atorvastatin 40 mg PO Daily

Ibuprofen 800 mg PO PRN

Allergies: No known allergies

Family History: Father is deceased, age 94, type 2 Diabetes and Osteoarthritis. Mother, age 88, Hyperlipidemia. One sibling, age 35, no significant medical history. One child, alive and well, no significant medical history.  

Social History: Lives in a house with spouse and children. Smokes 20 pack a year, drinks alcohol, denies using recreational drugs. He is active and plays golf 2 times per week with his friends. Current symptoms have affected his mobility.

Review of Systems

General: Well appearing, low tolerance of activity due to pain.

CV: The patient denies chest pain, palpitations, edema, or swelling of the extremities, dizziness. No history of heart murmur.

Respiratory: Denies SOB, cough, dyspnea.

Gastrointestinal: Denise abdominal pain, any change in appetite, any difficulty swallowing or chewing. Reports daily bowel movement.

HEENT: Denies of headache, nausea or vomiting, PERRLA. Denies epistaxis. No dentures or glasses.

Musculoskeletal: Denies any joint swelling, limited range of motion. No history of joint pain.

Neurologic: Denies headaches, NO syncope or seizures, no falls within the last 6 months, denies unsteady gait or problem with coordination.

Psychiatric:  Denies suicidal ideation, depression, alcohol or drug abuse.

Endocrine: Denies heat or cold intolerance, excessive thirst or urination, or tumors

Allergic: No known allergies

 

Objective

Physical exam

General: Pt is a well-developed, well-nourished 42-year-old Caucasian male.

Vital signs: BP 134/82, Pulse 88, Respirations 20, Temperature 99.2 F, O2 sat 99%, Weight 194 lb, Height 6’2

Skin: warm, no lesions or rashes noted. No cyanosis, pallor, or jaundice.

HEENT: Head normocephalic, atraumatic. PEARL, EOMs intact, no conjunctival infection, Ears symmetrical, sense of smell intact, tongue in the midline, face symmetrical, Neck Full ROM, no masses.

CV: RRR, no murmurs or rubs.

Respirations: Lung sound clear in bilaterally, no wheezes, no crackles.

Abdomen: No scars, soft, rounded, bowel sound present in all four quadrants, no masses, no guarding, no rebound tenderness. Liver and Spleen are within normal limits.

Neuro: Alert and oriented x3, no neuro deficit, CNII-XII intact, follow commands, speech clear, moves,  all extremities, Strength 5/5 and equal bilaterally, sensation intact, face symmetrical, tongue in the midline, DTRs 2+ equal bilaterally, no limp or foot drop.

Musculoskeletal: back pain radiates to the left leg, FULL ROM all extremities. No joint effusions, clubbing, or cyanosis.

Additional Diagnostic Tests:

Spinal X-rays can be ordered to detect spinal fractures, arthritis, infections, tumors and bone spurs however, these images will not provide issues with spinal cord, muscles or nerves.

MRI or CT scans reveal herniated disks and the location and cause of irritated nerve. An MRI can show the alignment of vertebral disks, ligaments, and muscles. A CT Scan with contrast dye can provide detailed images of the spinal cord and nerves.

 

 

 

Differential Diagnosis

 

Sciatica

The most important symptoms are radiating leg pain and sensory abnormalities. The sciatica pain affects only one leg and can be worse when sitting, coughing or sneezing. The leg may also feel numb or tingly and the symptoms can last for weeks. Sciatica is mainly diagnosed by history taking and physical examination. MRI may be used to indicate if sciatica is caused by infections rather than disk herniation.  Although epidural injections of corticosteroid might be effective the long-term effects are unknown. About 80-90% of patients with sciatic nerve pain improves however if symptoms do not subside in 6-8 weeks surgical options can be considered. (BW Koes & Tulder MW, 2007).

Lumbar strain

Lumbar muscle strain is caused when muscle fibers are abnormally stretched, or ligaments are torn from their attachments. Both of these can result from a sudden injury or from gradual overuse. It is the most common cause of lower back pain because it supports the weight of the upper body and is involved in moving, twisting and bending.   Symptoms include low back pain that may radiate into the buttocks, stiffness in the low back area, limited range of motion, inability to maintain normal posture due to stiffness.  (Allergri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini M and Fanelli G, 2016).

Spinal Stenosis

Spinal stenosis occurs when one or more bony openings within the spine begins to narrow and reduce space for the nerves. This process can occur within the spinal canal or in the intervertebral formation. Spinal stenosis may put pressure on the roots of the sciatic nerve. The narrowing of the formation in the spine usually develops over time as part of the aging process. While spinal stenosis typically occurs in people age 50, it can also develop sooner due to injury or congenital factors. Pain might be dull and confined to the neck or lower back, or it can radiate into the arms or legs, reduced sensation or strength may be experienced in extremities. (Bjerke B, 2019).

Compression Fracture

A compression fracture of the back occurs when the vertebrae collapse caused by back injuries or osteoporosis. This can lead to poor posture, pain, loss of up to 6 inches in height, and numbness or tingling in extremities, difficulty walking and moving. Pain worsens with flexion, and while pulling up from a supine to sitting position and from a sitting to standing position. Other causes of a compression fracture include osteomyelitis of the vertebra or osteogenesis. (Wong C and McGirt M, 2013).

Sacroiliitis

Sacroiliitis is an inflammation of the sacroiliac joint, usually resulting in pain. Often, it is a diagnosis of exclusion. The sacroiliac joint is one of the largest joints in the body and is a common source of the buttock and lower back pain. It connects the bones of the ilium to the sacrum. Sacroiliitis can be particularly difficult to diagnose because its symptoms are similar to many other common sources of back pain. It is often overlooked as a source of back or buttock pain. Pain from this condition is often due to chronic degenerative causes yet relatively uncommon. Sacroiliitis can be secondary to rheumatic, infectious, drug-related, or oncologic sources. Some specific examples of non-degenerative conditions that can lead to sacroiliitis are ankylosing spondylitis, psoriatic arthropathy, Bechet disease, hyperparathyroidism, and various pyogenic sources. NSAIDs and muscle relaxants can be prescribed during the acute phase of presentations. (Buchanan B & Varacallo M, 2020).

 

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